meeting user needs in national healthcare systems lessons from early adopter community pharmacists using the electronic prescriptions service

The aim of the study was to explore initial user experi-ences of CP professionals, and to ask if their needs were met concerning the development and implementation of EPS2.. A different

R E S E A R C H A R T I C L E Open Access

Meeting user needs in national healthcare

systems: lessons from early adopter community pharmacists using the electronic prescriptions

service

Jasmine Harvey1*, Anthony J Avery1, Ralph Hibberd2and Nicholas Barber2

Abstract

Background: The Electronic Prescription Service release Two (EPS2) is a new national healthcare information and communication technology in England that aims to deliver effective prescription writing, dispensing and

reimbursement service to benefit patients The aim of the study was to explore initial user experiences of

Community Pharmacists (CPs) using EPS2

Methods: We conducted nonparticipant observations and interviews in eight EPS2 early adopter community pharmacies classified as‘first-of-type’ in midlands and northern regions in England We interviewed eight

pharmacists and two dispensers in addition to 56 hours recorded nonparticipant observations as field notes

Line-by-line coding and thematic analysis was conducted on the interview transcripts and field notes

Results: CPs faced two types of challenge The first was to do with missing electronic prescriptions This was sometimes very disrupting to work practice, but pharmacists considered it a temporary issue resolvable with minor modifications to the system and user familiarity The second was to do with long term design-specific issues Pharmacists could only overcome these by using the system in ways not intended by the developers Some felt that these issues would not exist had‘real’ users been involved in the initial development The issues were: 1) printing out electronic prescriptions (tokens) to dispense from for safe dispensing practices and to free up monitors for other uses, 2) logging all dispensing activities with one user’s Smartcard for convenience and use all human resources in the pharmacy, and, 3) problematic interface causing issues with endorsing prescriptions and claiming reimbursements Conclusions: We question if these unintended uses and barriers would have occurred had a more rigorous

user-centric principles been applied at the earlier stages of design and implementation of EPS We conclude that, since modification can occur at the evaluation stage, there is still scope for some of these barriers to be corrected

to address the needs, and enhance the experiences, of CPs using the service, and make recommendations on how current challenges could be resolved

Keywords: User-centric approaches, Healthcare ICT, Usability, User experience, Social informatics in healthcare, Electronic prescription service release two

* Correspondence: jasmine.harvey@nottingham.ac.uk

1

School of Medicine, Division of Primary Care, Queens Medical Centre,

University of Nottingham, Nottingham NG7 2UH, UK

Full list of author information is available at the end of the article

© 2014 Harvey et al.; licensee BioMed Central Ltd This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and

The electronic prescription service (Release 2)

In England, it is part of the government’s agenda to enable

the writing and dispensing of electronic prescriptions to

patients The Electronic Prescription Service (EPS),

re-leased in stages one (EPS1) and two (EPS2) was designed

to meet this agenda Our study focused on EPS2 Sudgen

and Wilson [1] who piloted and evaluated early models of

the EPS, also known as the Electronic Transmission of

Prescriptions, documented the concept behind its

devel-opment Rai [2] explains the process of writing and

dis-pensing EPS2 prescriptions in detail, and Gourdrey-Smith

[3] explains its functions In summary, EPS2 is

informa-tion and communicainforma-tion technology that automates

prescription links between prescribing, dispensing and

pricing bodies for better patient care in the following

simplified format:

 Patient to General Practitioner (GP): GP (or

designated prescriber) writes prescriptions

electronically

 Electronic prescription to Spine: The electronic

prescription is sent to and stored on a national

database called the N3, commonly known as the Spine

Pharmacists (CPs) and their teams

patient to dispense their prescriptions can access

and download the prescription from the Spine, and

dispense it to the patient

The remuneration agency, formerly known as

Prescription Pricing Authority (PPA), is now called

NHS Prescription Services NHS Prescription

Services receives prescriptions from dispensers, such

as community pharmacies, calculates relevant

payments for the items dispensed and remunerates

dispensers for these With EPS2, details of items

dispensed are sent directly to NHS Prescription

Services electronically

Therefore, prescribers, dispensers, patients and the

pricing authority are key stakeholders in the successful

implementation of the EPS2 Figure 1 shows the original

EPS2 architecture given to the study team by the initial

overseeing body called Connecting for Health (CfH)

While the wider scope of the research project was to

evaluate changes in various forms made by EPS2 to all

stakeholders, in this paper we focus on community

phar-macies CP professionals were proposed to be one of the

key beneficiaries of the EPS2 for being able to provide a

better quality service because of improved work practices

The pharmacist from the first adopter pharmacy began

dispensing EPS2 prescriptions in July 2009 Although

EPS2 was still undergoing development at the time of data collection (February–September 2011), early adopters were dispensing between 10% and 40% EPS2 prescriptions (Table 1)

Since 2011, the National Health Service (NHS) in England, including EPS2 has been undergoing re-organisation EPS2 was originally part of the National Programme for

IT (NPfIT) to make Primary and Secondary care electron-ically interoperable in England [4], but it was designed to operate independent of other NPfIT programmes [2-5] When NPfIT was dismantled in 2011, some of its stand-alone programmes such as EPS2 were retained On 31 March 2013, the overseeing body of the NPfIT pro-grammes CfH ceased to exist Many of its functions, including the Electronic Prescription Service, have transferred to the new Health and Social Care Informa-tion Centre (HSCIC) On 1st April 2013, responsibility for supporting pharmacists in using these services transferred to NHS England (formally known as the NHS Commissioning Board) [6] The EPS2 national implementation programme is still on going

The aim of the study was to explore initial user experi-ences of CP professionals, and to ask if their needs were met concerning the development and implementation of EPS2 In the following, we briefly discuss key factors in new technology adoption and frame our research ques-tions within these contexts We then discuss our meth-odology, present and discuss our findings Please note that we use ‘early adopters’ to denote sites involved in the early stages of EPS2 implementation Also, note that

we use the term ‘real user’ to denote actual users of the system In this paper,‘real users’ are practising commu-nity pharmacists and their teams, and not any other type

of pharmacist

Some key factors in successful system delivery

or adoption

New systems or innovations are usually developed to solve a problem or aid a process A system development usually comprises several iterative stages in its lifecycle such as specification or problem-definition, feasibility study, analysis, design, implementation, evaluation and maintenance When a new system is being developed, many factors influence the planning stage [7] Key factors include: a) Financial aspects, which comprise of the cost of the system and the overall benefits b) Technical aspects, what can be accomplished by using existing technologies? and c) Social factors, which comprise changes the new sys-tem will be making to current work practices of the users, and how users will engage with the system comprehen-sively Some authors recognise this last factor, the social factor, as the most important in a system development concerning the systems acceptance and diffusion [8,9] Rogers, for example, names five determinants including

simplicity and ease of use, and, compatibility with

exist-ing values and practices as key factors in successful

adoption, and argue that the innovation is usually what

changes to suit the user and not the other way round

[9] Many systems fail or fall into disuse not because of

technical failure, but in how the technology is matched

to the social environment [10] The disengagement by

users, or a poor user experience directly affects financial

and technical factors and can render the system unusable

and detrimental [11-15] Consequently, there needs to

be a continuous engagement between the system and

the social environment to render a product usable [15]

In theorising the role technology plays in social

struc-tures, Greenhalgh and Stone [16] explained that, the

technological component of social structures may be supported when people choose to use the technology, and, not supported when they actively refuse to use it

or, importantly, cannot use it at all or in the ways they would like

In healthcare, Benn et al [17] lists“size, regional loca-tion, internal structure, management processes, history, external regulatory environment, culture and leadership”

as key variables that contribute to successful delivery of care systems However, similar to other theories, em-phasis is placed on social elements as a key factor in technology adoption Harvey et al [18] for example con-ceptualised that “socio-technical interdependence” is a key dimension in the adoption of new technology into pharmacy work practice Therefore, before new technol-ogy is effectively integrated into work practice, it is im-portant to note how the intended users interact with existing technologies in that environment In their study, which focused on the approaches to, and experiences of user engagement of the adoption of Lorenzo software into national EHR system in England, Cresswell et al [19] placed emphasis on user (dis)engagement For ex-ample, because real users such as hospital staff were not included in the system development process, this alienated them during the implementation process as they felt the system was then not sufficiently customised for their needs Furthermore, Gagnon et al [20] found that the boundary between barriers and facilitators in electronic

Table 1 Descriptive information of data collection sites

Site Percentage of EPS2 dispensed at time

of interview

EPS2 live since

4 Information not supplied but noted to be greater

than 10%

06.2011

Figure 1 Original EPS2 model and architecture (given to study team by Connecting for Health).

prescription systems’ adoption were blurred, and

recom-mended studies to be conducted from a variety of user

group perspectives Within these contexts, we frame our

research questions: what were CP professionals’

experi-ences of EPS2, what were their perceptions and attitudes

toward the new system, and what can be learned to

im-prove user experience and feedback to the implementers

in terms of meeting their needs?

Methods

Data collection

The research was part of the national CfH evaluation

programme commissioned by Department of Health to

evaluate how EPS2 will alter work practices The research

protocol was designed by a multidisciplinary study team

consisting of social scientists, academic and practising

pharmacists and a general practitioner The

methodo-logical framework was developed from literature reviews

on ‘user perception’ studies of new technologies [21-23],

electronic prescription adoption in healthcare [24-29] and

listed potential benefits of EPS2 according to CfH [30]

Rather than using standardised variables in ‘user

per-ception’ study models such as perceived ease of use

and perceived usefulness, we adopted a constructivist

(qualitative) approach by using flexible themes based

on user-perception studies, such as user’s perceptions

on positive and negative issues, perceived benefits, and

opinions on removing the system This approach allowed

us to delve deeper beyond standardised variables into

users’ candid perceptions

The data were collected between February and September

2011 In terms of sampling, we obtained a list of

pharma-cies classified as early adopters from CfH and selected

pharmacies that were‘live’ and dispensing above 5%

elec-tronic prescriptions The eight pharmacies that fell into

this category were in the midland and northern regions of

England (Table 1) Sites with different computerised

phar-macy management systems were chosen to get divergent

perspectives Other variations in the sites sampled

in-cluded type of ownership of the pharmacy (independent

or chain), geographic location and different software

suppliers Due to the small number of test sites (initial

adopters) at the time of the study, providing detailed

in-formation in this paper would breech confidentiality

and commercial sensitivity agreements Permissions were

sought from approval bodies at each of the study sites,

in-cluding Primary Care Trusts, research governance teams,

benefit realisation teams and informatics leads The study

protocol was submitted to the Cambridgeshire Research

Ethics Committee who classed the study as a service

evaluation

Data were collected using ethnographically informed

mixed methods including observations, formal (recorded)

and informal interviews, and shadowing of pharmacy

professionals Our chief participants were pharma-cists/pharmacist proprietors as they had overall insight

of the EPS2 integration into work practice We conducted audio-recorded interviews with all chief participants We also audio-recorded one accredited checking technician and one dispenser as additional participants We con-ducted 10 audio-recorded in-depth interviews The inter-views took 30 minutes to one hour, with transcripts for each averaging 3700 words Notes were recorded from the participants too occupied with work to give audio-recorded interviews While the pharmacists were generous

in allowing us access to their sites and permitting inter-views, the busy nature of the job meant there were time constraints

Analysis

Overall, 37, 200 words from the transcripts were ana-lysed besides the field notes Both types of qualitative data were analysed using line-by-line coding (Figure 2) and thematic analysis Each line was coded into sub-themes and into sub-themes Themes were then recoded into positive and negative issues This identified experi-ences associated with usability and user experiexperi-ences thereby achieving a bottom-up analysis EPS is a stan-dardised system that has to be integrated with different pharmacy dispensing systems, meaning CPs have a choice of who their ‘pharmacy system-EPS’ supplier is [31] The eight sites had different pharmacy system sup-pliers Bearing this in mind, we focused our analysis on common issues among the sites to remove supplier spe-cific issues

Analysis showed that CP professionals were overall posi-tive about the system and wished for it to be retained and improved, instead of being discontinued [32] They were however facing two types of challenges with the system The first type of challenge was caused by missing elec-tronic prescriptions Sometimes, when the prescriber wrote the prescription, pharmacists nominated by the patient to dispense the prescription could not see or download the prescription for dispensing This issue was especially challenging for pharmacists as there were different causes with no adaptable solution within phar-macy work practice Pharmacists, however, considered this a teething issue that could be resolved by small modifications to the system [32] The second type of challenge was considered long-term and was specific to the system design Although these design specific issues were adaptable into work practice with‘add-on’ designs, pharmacists thought these issues were present because they were not involved in the system design and devel-opment We decided to present the two challenges in two papers to allow us to discuss the issues (with user commentaries) in detail In this paper, we present our set of second type challenge in the EPS2 adoption

We found there were some essential user needs that

were not met These caused users to interact with the

system in ways not intended by the system developers,

and interfered with how CP professionals experienced

the system These were, 1) dispensing from printed-out

tokens instead of screens, 2) using one Smartcard to log

all dispensing activities by different staff, and, 3)

prob-lematic interface for claiming reimbursements

Printing tokens

A key aspect of the EPS2 design was to decrease paper

prescriptions by electronically writing and dispensing

prescriptions Figure 3 shows how the system was

de-scribed in the patient and carer information leaflet [33]

This means prescribers have to record the medications

electronically on their computer screens and dispensers,

after downloading the prescription, can dispense them

directly from the screen without any need of a paper

The pharmacists we interviewed would not dispense

from a computer screen, as they feared it would

com-promise safety They felt that the best practice was to

have a paper prescription beside the medicines they were

dispensing This enabled dispensers to check

medica-tions they were picking from the shelves against the

paper in hand, and allowed pharmacists to conduct the

final professional check of the dispensed items from any

location in the pharmacy Pharmacists felt that

dispens-ing from computer screens would not only hinder this

form of verification but restrict access to the computers

as the following excerpts demonstrate:

I don’t know whether their initial aim was to dispense off the screen or check off the screen, you know, but I wouldn’t check off the screen or dispense off the screen

Figure 2 Sample line-by-line coding method.

Figure 3 NHS EPS2 patient and carers information leaflet

in England.

at all I need a piece of paper in front of me, so that

defeats the purpose of the electronic prescriptions”

(Site 3, Pharmacist)

“Often, you are too busy in a pharmacy to be able to

dispense from the screen You might have to run your

labels off and you need something to check from”

(Site 1, Pharmacist)

“I don’t ever see—I don’t know if you could ever get rid

of the paper aspect, because I think that I wouldn’t

like to check three prescriptions of five items, fifteen

items looking at a TV screen I think I would end up

kind of cross-eyed It’s much easier to look at a piece of

paper” (Site 8, Pharmacist)

CPs felt they would have made this known had they

been consulted in the EPS2 design Consequently,

in-stead of directly dispensing medication from computer

screens, community pharmacists have deviated from the

original EPS2 design by opting to print out the

elec-tronic prescriptions after downloading them onto their

screens These printed electronic prescriptions,

com-monly known as tokens, were then used to dispense

medications Although tokens are not legal prescriptions,

they provide a hard copy of data from the electronic

pre-scription, so were accepted by pharmacists for use in

dispensing In addition, printing the tokens enabled

pa-tients to have a physical possession of their medication

information, as explained by this pharmacist:

“You might need the token to be able to check your

items to the labels Also, you need the repeat slip for

patients attached to the token Patients aren’t going to

be able to order again unless they get something in their

bag and they can order next time To do that you need

to print the token If the patient is exempt in some way

or pays for the prescription, it has to be filled in on the

back if they are not age exempt If they are under 16, or,

over 60, you don’t have to use that paper copy However

you still need the repeat slips, you still need to fill in the

exemption and get it signed on the back to show that the

patient has an exemption or has a certificate to show

that they don’t pay” (Site 1, Pharmacist)

On 10 October 2012, E-health Insider (EHI) featured an

article that showed plans for the NHS to be paperless by

2015 [34] From these interviewee commentaries, it is

ap-parent that the paper-free design of EPS2 is challenging to

its users in practice Paper prescriptions are small, light

and mobile and can be annotated, for example, in the final

safety check the pharmacist can tick each item on the

paper as it has been confirmed correct, allowing them to

be interrupted and regain their place without losing

accuracy Perhaps other ‘paper-free’ alternatives could be explored such as using tablets to take screenshots of the electronic prescription for portable dispensing A chal-lenge in relation to printing of tokens is the additional cost; that pharmacists take this on without reimbursement shows the printing has value to them

Smartcard policies

EPS2 was designed to be a Smartcard system to enable access to the Spine Health professionals who need ac-cess to the Spine have to apply for Smartcards from the Registration Authority usually the local Primary Care Trust (PCT) [3] Since EPS was designed to use ‘a single card’ model of access, individual Smartcards are required for each user Users cannot share Smartcards or even share access sessions The purpose of this is to have an audit trail of users of the Spine [3,35] Generally, the Smartcard system was not used as intended Community pharmacies are places of constant rapid physical acts ful-filling the prescription; time at a terminal is a relatively small part of this and terminals are often used by several people CPs felt that this was the more practical usable method since multiple users did not have to keep log-ging in and out of the system Consequently, the first person who logged into the system left their Smartcard

in until they finished work for the day then someone else would take over as the main logged-in user as the fol-lowing excerpt demonstrates:

“We do all have individual Smartcards We all can use an individual Smartcard It would just tend to be whoever has been logged in first thing in the morning

as the person who would end up doing that most of the day S goes home at half past four, for instance, and then someone else would have to do it SE would probably log-in, she leaves at six and then whoever is

in this evening would log-in It just depends really as

to who is in first thing in the morning But yeah, that’s just the way it goes” (Site 5, Pharmacist)

The main reason behind this approach was conveni-ence as the logging in and out by different users would significantly interfere with workflow and reduce prod-uctivity, especially at peak hours Some pharmacists also argued that the reason behind using one Smartcard was to distribute the workload as widely as possible In the following, pharmacists give more explanation of their reasons for not using Smartcards for each mem-ber of staff:

“No, we should do [log-in individually], but we don’t Because three dispensers, well three people, have the Smartcard in the pharmacy and in fact there is probably five people in the pharmacy that can do all

of the jobs and if we kind of religiously stuck to the

Smartcard [rule], two people would be isolated away

from the computer not being able to dispense I log-in

at the beginning of the day and it’s left there My

re-sponsibility if anything happens untoward, but I can’t

understand what it could be, because they are doing

NHS prescriptions all the time anyway, and they are

used to doing that, and they’ve signed the Data

Confi-dentiality and Data Protection Act” (Site 8,

Pharmacist)

“We keep our own We’ve [each] got a screen, a

monitor each, maybe because there is only two of us so

X keeps her Smartcard and if I’m not in and if there is

a locum in, X will download all the prescriptions,

because well, our regular locum does have her own

Smartcard and she will bring that and use that But if

you use an agency locums, they wouldn’t necessarily

have a card and then everything would go through X”

(Site 6, Pharmacist)

Clearly, this was not how the system was designed,

continued use this way could breach security and might

become an issue if pharmacists have access to patients’

electronic health records Since EPS2 is still undergoing

product development through modifications, perhaps

this feature could be modified in a way that would not

require the logging of every user’s activity

Prescription endorsing interface

Getting the interface right in any system development is

often the biggest challenge The interface of a system is

a self-contained feature and includes getting a range of

multiple items right such as the aesthetics, clarity in

dir-ection of use, colours, and user’s emotional conndir-ection

with it [36] A key interface issue that has arisen at the

evaluation stage of the EPS2 is interacting effectively

with the endorsing and claiming interface When

pre-scriptions are dispensed, pharmacists have to send off

the prescription details to NHS prescription service,

which has several functions including reimbursing the

price of the purchased medicines and the professional

fees incurred by pharmacists Under the paper system,

the prescriptions are collated and sent off manually to

the pricing body; under the EPS2, this is done

electron-ically using the‘endorsing and claiming’ interface The

problem some pharmacists appeared to be having with

EPS2 interface is effectively interacting with it to claim

back charges incurred after dispensing Since a

Com-mon User Interface (CUI) that would integrate with

different types of pharmacy systems was not developed

[37], some pharmacy systems adapted better to

endors-ing and claimendors-ing than others Consequently, some

pharmacists had more issues than others However, a

common concern involved ‘NCSO’ claiming, as this pharmacist explains in detail:

“NCSO means No Cheaper Stock Obtainable

Normally everything gets endorsed by the computer, by the endorsing machine Certain items have to be endorsed manually [not automatic but completed on screen] if it’s specialised and controlled drugs or NCSO Every month, the Department of Health, they produce a list Sometimes it’s quite a big list, ten, fifteen items and sometimes it’s only one or two items For example, this month, 20 mg tablets is on the NCSO list That list only gets published about the tenth of each month Everything I’ve done from the first to the tenth, I don’t know whether that item is going to be on the NCSO list With NCSO, what I have

to do, I have to sign it, and I have to date it and I have to put the price I’ve paid for it So the (Inaudible 00.12.22) might be £2.50 for example What I’ve paid for it is £10 If I can’t endorse it as £10 I lose £7.50.” (Site 3, Pharmacist)

The encouragement by NHS Connecting for Health of pharmacists to regularly claim electronically for reim-bursement (to reduce high flows at the end of the month) means that they may not get reimbursed for NCSO list items that they have dispensed and sent off for reimbursement early in the month This issue has led pharmacists to become concerned about losing income

as noted in the following extracts:

“We are still having problems transmitting a lot of data

to pricing bureau Last month, I think we had about two dozen in total that wouldn’t allow them to be

electronically submitted Our main problem is, when you come to do your ETPII endorsing on [software system 2], I think it was the same on [software system 1]

If you supply, say aspirin tablets and you say aspirin tablets and it has a manufacturer next to it Tabba Actevis What we’ve done is, we’ve obviously ticked the NCSO button Because we’ve logged in, we assume that’s

as good as a signature for them, which it is, apparently and we sent the data off for months and months and months We haven’t been paid for any NCSO for months” (Site 2, Pharmacist Proprietor)

“When we endorse, often there is prescriptions that just won’t go They won’t send so we’ve [wrongly] paid for numerous prescriptions where I’m going to have to sit down with X from the PCT [Primary Care Trust] next week and go through them all and see whether we can chase these payments Some of them are over six months old, so then we’d have to request the doctors to reissue One of the endorsing issues was for PIs imports

that should get paid the same as a normal English

pack The C programme was asking for a

supplementary payment, which is not required for

this item But because I’ve spoken to pharmacists who

work in a pharmacy and obviously [they’ve] spoken to

a pharmacist who has been stuck in their computer

room for the last ten years, they don’t realise what’s

going on They basically said to us, well, for it to go

you need to put a payment in or a supplementary

payment They said, well, just put a penny in and

they will pay you for the right amount Some of these

cost a lot of money I said well, I tell you what then, if

they are going to pay the right amount, why should I

put a penny in and risk it I’ll put £10,000 in shall I,

and then I will get paid still the right amount and

not the £10,000 If it goes wrong, I’m at least on the

right side of it So then I get the PPA ringing me up

and wondering why I’ve endorsed a load of

prescriptions for millions of pounds and then again

I’m under stress again, because the PPA are accusing

me then of trying to claim lots of money, I was just

trying to prove a point” (Site 1, Pharmacist

Proprietor)

These detailed commentaries define an interface

prob-lem that appears to be causing monetary stress to some

pharmacists Since the interface was not user-friendly,

users had to look for alternative ways to claim

reim-bursements of NCSO items

Discussion

Usability and user experience: meeting user needs

In our findings, CP professionals’ needs were not met,

particularly in how the system was designed so they

had to find ways to adapt them to their needs The

us-ability and user experience issues identified did not

conform with key facilitators of technology adoption

such as ease of use and compatibility [9,38] While an

explanation of the unintended uses could be attributed

to CPs collective resistance to change, it does not

ap-pear as if the system was tailored to their needs in the

first place, which is a key facilitator of technology

adop-tion A different explanation to these design specific

is-sues could be due to the lack of CPs’ perspectives in the

design and development of the EPS2, as demonstrated

by this comment:“But because I’ve spoken to pharmacists

who work in a pharmacy and obviously [they’ve] spoken to

a pharmacist who has been stuck in their computer room

for the last ten years, they don’t realise what’s going on”

Whether or not this statement is justified, in the following,

we use the concept of user-centric principles to explore

and discuss how the involvement of CPs as a key user

group in the EPS2 development might have enhanced

their experience

User-centric approaches and active user involvement

To meet user needs in terms of system design, users are often involved in the system development process [38] Applying user-centric principles, such as user-centred design, which moulds the design of the system to suit its intended users, is recognised as best practice [39] Stud-ies have shown that national healthcare Information and Communication Technologies (ICTs) development such

as Electronic Health Records (EHRs) tend to fail in user engagement [19] A key reason for this is, users tend to

be excluded from the initial stages, and are usually in-volved only at later stages, thereby making critical modi-fications to the system design either expensive or impossible [40-42]

Involving users in a new system development can take several approaches While active involvement of users is sometimes seen as overindulging by allowing users to specify unnecessary functions [43], the application of user-centric design is usually seen and adopted as best practice in a system development User-centred design, sometimes also referred to as ‘user-centred system de-sign’ is a human-computer interaction strategy to in-volve end-users in a new system or service development The meaning of UCD has become vague since it was coined by Norman and Draper [44], however, its aim is

to place emphasis on user engagement, and improving how the user experiences the system when implemented

It focuses on users by learning about the context of their work, the environments they work in, and their needs for usable products [45] In short, the aim of UCD is to create a better user experience for the people for whom the system was designed In practice, UCD faces many challenges as it can be applied using several approaches [39,45] Using common approaches to UCD, Gulliksen

et al [39] developed key principles that underpin its ap-plication in a system development, and these are:

 The early focus on users’ work practices and tasks to control the development,

 Active user participation in the analysis, design, development and evaluation,

 Early prototyping to gradually build a shared understanding of user needs as well as future work practices,

 Continuous iteration of designed solutions,

 Integrated design that involves the system, the work practices, online-help, training, organisation, etc

The theory about the application of these principles is that they will improve the usability of the product and its User Interface (UI) such as ease of use, efficiency, reduced error, and user satisfaction UI has especially become a current focus of UCD practices as it enables users to

familiarise themselves with the product’s interface early

[46] When detailed iteration takes place in the later

stages of the development, it is more expensive if the

design follows a stage-gate model from conceptual to

detailed design Meaning each design step sets

con-straints on the next and hence any change in design at a

later stage is more expensive than at an earlier stage

[47] Using this perspective, we put into context how a

UCD approach could have been used to mould CP

pro-fessionals’ experience of EPS2

Putting user-centeredness into context

While reasons such as lack of technical and other forms

of support, no added value in terms of finance, or even

re-sistance to change could be explanations for why CPs

could not interact effectively with the design of EPS2

[9,20,38], active user-involvement could be another

ex-planation Firstly, in terms of dispensing directly from

screens, CPs elected to print and dispense from tokens

be-cause various usability requirements such as equipment

sharing, job sharing, multi-tasking, and providing advisory

slips to patients made dispensing directly from screens

challenging This issue was evident during the piloting of

various models at the concept evaluation stage [1]

How-ever, it appears the issue was not explored further or

re-solved before latter stages, as it would have also been

evident during the prototype testing stage Secondly, in

terms of CPs electing to use a single smartcard for

mul-tiple users, a key practice of UCD is to perform detailed

task analysis of users’ work to design systems that would

improve (not interfere) with workflow [45] Using multiple

user log-ins to achieve accurate audit trails appears a

feasible concept In practice however, the concept was

challenging for CP professionals as it interfered with

workflow They therefore adapted the Smartcard’s

us-ability to suit their needs by using one Smartcard to

serve multiple users This issue was evident in our EPS2

pre-implementation study of pharmacy work practice as

pharmacists showed signs of not using EPS2 Smartcards

as intended We fed back our findings to participating

PCTs as part of our formative evaluation [48] However,

this issue could have been evident much earlier at the

concept evaluation stage when the idea of EPS2 (and

this function) was being marketed to users It could also

have been identified during the user’s task analysis or

even the prototyping stages of user-centric approaches

Lastly, since a common user interface to integrate with

different types of pharmacy managing systems was not

developed, pharmacists had to find ways to deal with

the NCSO claiming and endorsing function Prototype

testing by users from various dispensing systems could

have aided a better NCSO UI design across all systems

We do not know to what extent user-centric approaches

were used and how rigorously they were applied as we

could find very little information on this It is possible that these design issues were identified at earlier stages but were not resolved at later stages of the system develop-ment, however, the purpose of active user involvement is

to mould the system to user needs before it becomes too expensive to resolve [47] While, there may be other ex-planations for why users could not integrate these EPS2 features into work practice, our study suggests that lack of active CP user groups in the early stages of system devel-opment may have been the main problem While engaging users at later stages allows them to touch and feel the ac-tual product and not just a concept, active involvement in the initial stages is more participatory and allows users to contribute to the design based on their needs The EPS2

at its evaluation stage clearly showed some important technical barriers that could have perhaps been eliminated had real users been meticulously and actively involved in the initial stages of its development

Strengths

We have built on work done by Cresswell et al [19] on user engagement by focusing on community pharmacists and their teams as a key user as key user group in the de-livery of the national Electronic Prescription Service (EPS)

in England Our focus on English community pharmacies (and primary care) in this paper contributes new know-ledge because most of the user-perception literature on national electronic prescriptions systems relates to other parts of Europe and America, and focuses on general practice (GP) or secondary care [20,24-29]

Limitations

We emphasize that these are only preliminary findings from early adopter sites, and suggest further studies to establish how the system operates when more mature

We acknowledge that with a small sample our findings may not be generalisable to other community pharma-cies, or fit with the experiences of pharmacies that adopted EPS later However, our aim is to draw attention

to involving user group perspectives into systems’ devel-opment regardless of whether the issues were still per-sistent at the time of writing this article Overall, there is scope for further studies once EPS2 has been imple-mented more widely This could help determine whether issues we have identified have been resolved and/or whether new issues have emerged

Conclusions

Using detailed commentaries from the study of early adopters, we have drawn attention to some key issues in national healthcare system development from a commu-nity pharmacy perspective Firstly, pharmacy professionals needs were not meet in terms of the system design as they had to appropriate certain aspects of the system to suit

their needs Secondly, the process of involving users should

be made publicly available to reassure users and to make

the development process transparent Thirdly, our findings

suggest that involving real users in the service or system

design from the initial stages and throughout the

develop-ment life cycle could help enhance usability and user

expe-riences, or at least flag up cases in which national policy

will be detrimental to local activities While we

acknow-ledge that many pharmacists were over all in favour of the

system, EPS2 at this early evaluation stage clearly showed

some key usability and user experience barriers that could

have perhaps been eliminated had real users been

meticu-lously and actively involved in the initial stages of its

devel-opment We conclude that since EPS2 at the writing of

this article is in its evaluation stage, these issues can still be

addressed through modifications and perhaps system

re-design, and would help meet the needs of community

pharmacies and improve their user experience

Recommendations

Our recommendations take into account that the EPS is

still evolving, and therefore need long term (or

futuris-tic) solutions to the design challenges faced by

pharma-cists, if a paperless NHS is to be achieved

1 Paperless alternatives to the prescription should be

developed and assessed with users

2 Alternative governance arrangements, or different

technology (such as biometric identification), is

needed to allow several different users to use the

same terminals without delay

3 In terms of interface challenges of claiming and

reimbursement, pharmacists could be encouraged to

make NCSO claims, after the list is published by the

Department of Health, while EPS is evolving In the

long term, we recommend that pharmacists make

their collective voice heard regarding this issue so

that a more acceptable‘standardised’ interface could

be achieved

4 Pharmacists should form powerful user groups to

work with each of the pharmacy management

system suppliers

Competing interests

The authors declare they have not competing interests.

Authors ’ contributions

JH facilitated the refinement of the research design, was the primary data

collector of the study She conducted the in-depth interviews and recorded

the nonparticipant observations field notes from all eight early adopter

phar-macies JH conducted the analysis and interpretation of the data with AA

and NB and other members of the team, and led the writing of this paper.

AA co-authored and edited all the cases studies from the study, extensively

contributed to the analysis and the interpretation and of the data and

pro-vided commentary on the writing up process RH propro-vided insights into user

group involvement in the EPS2 planning and development by interviewing

the relevant technical architects and making available user group meeting

contributed to the analysis and critical interpretation of the data analysis and provided key insights to improve the paper All authors read and approved the final manuscript.

Authors ’ information

JH is a social scientist and specialises in Social Informatics, in particular, ethnological study of peoples ’ (dis)engagement with technologies She has a multidisciplinary background in human sciences, information science and information technology She works with Professor Tony Avery at the School

of Medicine, University of Nottingham JH previously worked at the Department of Social Sciences, Loughborough University, and WMG at the University of Warwick.

AA is professor of Primary Health Care at the Division of Primary Care, School

of Medicine, University of Nottingham Among other interests, he specialises

in patient safety and the use of information technology to aid clinical practice, and has an extensive portfolio and high starred academic papers for both quantitative and qualitative research in this field AA is also an active general practitioner in the city of Nottingham.

RH was a Research Fellow at the Department of Practice and Policy, University College London School of Pharmacy, University of London RH has

a background in technical design and engineering His position as the lead researcher of the EPS2 project enabled him to gain critical insight into EPS2 development as he has access to implementer and user group meetings and, liaised closely with Connecting for Health.

NB is professor of the Practice of Pharmacy at the Department of Practice and Policy, University College London School of Pharmacy, University of London NB gave a critical insight throughout the research write up NB is also a visiting professor of medication safety at Harvard Medical School and

is a practising pharmacist.

Acknowledgments

We thank all the pharmacies that took part of the study despite having a lot

to grapple with We also thank the individuals from Connecting for Health and the technical architects who gave us insights into EPS2 planning and development We thank the informatics leads from the Primary Care Trusts who allowed us access to these early adopter sites Finally, we thank the wider project team for their feedback in the analysis and interpretation of the results.

Disclaimer This report is independent research commissioned by the National Institute

of Health Research The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.

Author details

1 School of Medicine, Division of Primary Care, Queens Medical Centre, University of Nottingham, Nottingham NG7 2UH, UK 2 Department of Practice and Policy, UCL School of Pharmacy, Mezzanine Floor, BMA House, Tavistock Square, London WC1H 9JP, UK.

Received: 29 January 2013 Accepted: 4 March 2014 Published: 10 March 2014

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